FORM 'F'

[See sub-rule (1) of rule 6]

Nomination

To THE BOSTON CONSULTING GROUP (INDIA) PVT LTD

1. Shri/Shrimati/Kumari ……………………………………………whose particulars are given in the

statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable after
my death as also the gratuity standing to my credit in the event of my death before that amount has
become payable, or having become payable has not been paid and direct that the said amount of gratuity
shall be paid in proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of
clause (h) of section (2) of the Payment of Gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section (2) of the said Act.

4.
(a) My father/mother/parents is/are not dependent on me.

(b) my husband's father/mother/parents is/are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the to the Controlling Authority in
terms of the proviso to clause (h) of section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Name in full with full Relationship with the Age of nominee Proportion by which
address of nominee(s) employee the gratuity will be
shared
1.
2.
3.
so on.

Statement
1. Name of employee in full.
2. Sex.
3. Religion.
4. Whether unmarried/married/widow/widower.
5. Department/Branch/Section where employed.
6. Post held with Ticket or Serial No., if any.
7. Date of appointment.
8. Permanent address.

Village ……………… Thana ……………… Sub-division ………………. Post Office ………………

District ………………. State…………………

Place Signature/Thumb impression

Date of the employee
 Declaration by witnesses

Nomination signed/thumb impressed before me.

Name in full and full Signature of witnesses.

address of witnesses.

1. 1.

2. 2.

Place

Date

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this
establishment.

Employer's Reference No., if any.

Signature of the employer/ officer authorized

Designation -

Date: Name and address of the establishment or rubber stamp

Acknowledgement by the employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

Date Signature of the employee